Community services for care homes

Falls and Fracture Prevention Service (SCFT)

Support available includes:

  • Initial assessments conducted at the home or providing telephone advice after a resident has fallen
  • Assessment of the individual as well as their environment and equipment
  • Providing patients with home exercise programmes
  • Training and education sessions to care homes

Referral pathway

Referrals can be made via:

Proactive Care (SCFT)

Proactive Care is a multi-disciplinary team (MDT) approach to case management which seeks not only to ensure that planned care is well coordinated and comprehensive but that predictable risks associated with the patient’s wellbeing are identified and planned for. The improved patient experience will include the reduction of unplanned admissions.

The MDT consists of community nursing, social workers, OTs, Physios, Community Pharmacists, Mental Health Nurses and support workers as well as primary care colleagues including the GP.

Patients who are frail or otherwise at risk of deteriorating care and who would benefit from a MDT approach to care planning and delivery can be referred to the Proactive Care Team via OneCall (see below).

Referral pathway